I found this interesting; complex, but interesting:

Managed Care Experts and Oncologists Discuss Reimbursement, Access Issues Associated with Expensive New Cancer Therapies

Expert panel convened by the American Journal of Managed Care provides insight into the challenges faced by clinicians and payers when administering cutting-edge cancer medications.

Plainsboro, NJ – August 19, 2013 — Researchers have made powerful new targeted treatment options available to oncologists who treat patients with breast cancer. One such option, pertuzumab, is a recombinant humanized monoclonal antibody that is approved for use in combination with trastuzumab and docetaxel for the treatment of patients with HER2-positive metastatic breast cancer.




In one clinical trial, women treated with combination therapy with pertuzumab experienced significant improvements in progression-free survival (six months greater on average) compared to women who received combination treatment with placebo.

However, while drugs like pertuzumab offer the promise of improved outcomes in patients with breast cancer, the high costs associated with these regimens raise questions about access as payers assess the value of treatment.

These and other key issues surrounding proper utilization and reimbursement were the focus of an expert panel discussion convened by the American Journal of Managed Care.

The discussion, moderated by Michael E. Chernew, PhD, a professor in the Department of Health Care Policy at Harvard Medical School and Co-Editor-in-Chief of the American Journal of Managed Care, also featured Lee N. Newcomer, MD, MHA, Senior Vice President of Oncology for UnitedHealthcare, and Sandra M. Swain, MD, Medical Director of the Washington Cancer Institute at Medstar Washington Hospital Center in Washington, DC.

The panelists examined the demographics of the patient population eligible for treatment with pertuzumab and another promising new treatment, Kadcyla (trastuzumab emtansine), also known as TDM-1. They also reviewed results from several clinical trials that examined treatment using these medications alone and in combination, with Dr. Newcomer noting that the survival benefits seen from TDM-1 in the EMILIA trial are “probably one of the best responses we have seen in breast cancer in almost a decade.”

Such promising trial results have raised the profile of these drugs among clinicians and patients. Dr. Swain said there was “an immediate request for those drugs as soon as they became available on the market… breast cancer patients were following this news just as closely as the physicians.”

Although these medications have demonstrated proven efficacy, the panelists noted that because these agents cost hundreds of thousands of dollars a year to administer, payers have to carefully assess their value to ensure cost-effective access to eligible patients.

Dr. Newcomer, speaking on the question of treatment cost vs. efficacy, said these drugs are making a “substantial impact on both survival and how long the tumor stays away. The question for payers is figuring out “how much we can afford to pay for those kinds of responses.”

The panelists discussed a host of issues related to reimbursement and pricing, including:

– The disadvantages for some Medicare patients in terms of out-of-pocket expenses compared to patients with private insurance

– The challenges to medication access due to declining Medicaid budgets

– The effect of Medicare’s low rate of reimbursement for administering these drugs on overall health care costs

Finally, the panelists closed the discussion by examining the potential effect of new payment models on practice patterns and treatment selection, particularly models that cap payments to physicians unless they can show that a particular treatment choice improved outcomes.

Visit www.ajmc.com/ajmc-tv/panel-discussion to access the audio of this panel discussion, as well as additional installments covering other topics in managed care.

About the American Journal of Managed Care

The American Journal of Managed Care is an independent, peer-reviewed publication dedicated to disseminating clinical information to managed care physicians, clinical decision makers, and other healthcare professionals. Its aim is to stimulate scientific communication in the ever-evolving field of managed care. The American Journal of Managed Care addresses a broad range of issues relevant to clinical decision making in a cost-constrained environment and examines the impact of clinical, management, and policy interventions and programs on healthcare and economic outcomes.

What do you think?  Huge challenges lay ahead for medical community, insurance companies and the government.  But of course everyone will work together and help to fix things seamlessly, right?  How discouraging!

But at least someone is trying to get started.  Feel good and keep smiling!  Pat

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